USE THIS TYPE OF TABLE AND FONT STYLE

SECURE THE PPT OF THE TOPICS ASSIGNED TO YOU

CRITER
IA

EVIDENCE

cough, difficulty of breathing, sputum production

STATEMENT/STUDY (CITATION)

STATEMENT/STUDY (CITATION)

STATEMENT/STUDY (CITATION)

POIN
T

USE THIS TYPE OF TABLE AND FONT STYLE

SECURE THE PPT OF THE TOPICS ASSIGNED TO YOU
CRITER
IA

EVIDENCE
POIN
T

Relief of breathlessness and exercise limitation (American

Thoracic Society, 2013)

This selectivity of muscarinic antagonists accounts for their

usefulness as investigative tools in examining the role of
parasympathetic pathways in bronchomotor responses but
limits their usefulness in preventing bronchospasm with
minimal drug tolerance (Katzung, Masters, & Trevor, 2012).

2/4

Their duration of action is approximately 6 to 8 h, but

compared with SABAs, they have a slower onset of action
but have longer duration of action.(Cazzola et al., 1998;
Gross, 2006).
Short-acting anticholinergics are not taken as a
monotherapy for exacerbation and is always used in
combination with SABA because of its slower onset of

USE THIS TYPE OF TABLE AND FONT STYLE

SECURE THE PPT OF THE TOPICS ASSIGNED TO YOU
CRITE
RIA
1

2/3

EVIDENCE
POIN
T

Reversible symptoms of: paradoxical acute

bronchospasm, cough, throat irritation and dry
mouth in 15% but is due to long term use. (Guy,
2011)
Inhaled ipratropium shows little or no evidence of
adverse hemodynamic or ocular effects, or
detrimental effects on salivation, micturition, or
arterial blood gases due to its low lipid solubility,
therefore poor absorbability (even in GIT) and does
not pass the blood-brain barrier (Cazzola et al.,
1998)
Bronchodilatory effect may be intensified by -

++

CRITERI
A

EVIDENCE

Inhaled mAChR antagonists have been used as treatments for

respiratory diseases including COPD but is not a recommended
as the first line therapy for patients with COPD (GOLD Cat B).

SAMA.Short-acting anticholinergics are not taken as a

monotherapy for exacerbation and is always used in combination
with SABA because of its slower onset of action (American
Thoracic Society, 2013).

No contraindication to the patients clinical features.

POIN
T

SAMA is contraindicated in patients with hypersensitivity to atropine-like substances.

Special precautions in taking the drug must be given to patients with narrow-angle
glaucoma & prostatic hypertrophy, cystic fibrosis.

Long-term SAMA monotherapy on regular basis is not

recommended due to its short-lasting form which works in about
15 minutes and lasts for 68 hours, and is usually taken 4 times a
day which diminishes patients compliance to the drug (Voshar,
et.al., 2008).

CRITERIA

PRICE PER WEEK

POIN
T

Ipratropium
bromide
(Atrovent inhalation
soln)
0.5mg/2ml
3-4 puffs per day

STOCK: 20 puffs x 1s (P1,594.00/box)

PER WEEK: 21-28 puffs/week
PRICE: P2231/week

CRITERI
A

EVIDENCE

1/2

Studies showed a consistent improvement in lung

function and dyspnea scores in patients. (Dahl
et.al.,2001; Friedman et.al., 2001; Wabdo et.al., 2002).

++

Long-term studies have shown no evidence of

diminished responsiveness (tachyphylaxis) with regular
therapy. (Seale, 2006).

The bronchodilating effects of short-acting inhaled

anticholinergics last longer compared to the short-acting
beta-agonists, with some bronchodilator effects lasting
up to 8 hours after administration. (GOLD, 2013)

POIN
T

CRITERI
A

EVIDENCE

1/2

Clinical trials have also shown chronic use of LAMAs not

only reduces airflow limitation due to the disease but are
also associated with improvements in quality of life,
symptom scores and reduced exacerbations (Decramer
et.al., 2014; Wedzicha et.al., 2013; Vincken et.al., 2002).
Studies observed the ability of LAMAs to suppress mucus
secretion thereby reducing the colonization with bacteria
that trigger exacerbation events (Decramer et.al., 2014)

++

Long-term studies have shown no evidence of diminished

responsiveness (tachyphylaxis) with regular therapy.
(Seale, 2006).

Tiotropium,
once
administered
the
onset
of
bronchodilation occurs within 30 minutes, with peak
activity at 3 hours and sustained over more than 24

POIN
T

CRITERI
A

EVIDENCE

1/2

Studies of LABA/LAMA combinations, to date, indicate

that combining different classes of bronchodilator results
in significantly greater improvements in lung
function and other meaningful outcomes such as
inspiratory capacity, dyspnea, symptom scores,
rescue medication use, and health status in
comparison with individual drugs. (Van der Molen et.al.,
2013)

11 studies in total with more than 10 000 patients across

52 countries, has documented a significant improvement
in lung function and patient-reported outcomes including
breathlessness and rescue medication use compared
with current standard of care, reduced rates of COPD

POIN
T

CRITERI
A

EVIDENCE

Once administered the onset of bronchodilation occurs

within 30 minutes, with peak activity at 3 hours and
sustained over more than 24 hours. After regular once
daily inhalation, it reaches a steady state after 2 weeks
and is sustained a week more than a monotherapy of
LABA or LAMA. (Mahler et.al., 2013)

POIN
T

CRITERI
A

EVIDENCE

Reversible symptoms of: paradoxical acute bronchospasm, cough,

throat irritation and dry mouth in 15% but is due to long term use.
(Guy, 2011)

2/3

POIN
T

In the Lung Health Study, mortality and hospitalization due to

cardiovascular disease were highest among patients of mild-tomoderate COPD using ipratropium. (Anthonisen et.al., 2002)
Two large retrospective observational studies have also shown
that recent use of ipratropium is associated with an increased
risk of cardiovascular events and mortality. (Lee et.al., 2008,
2010)
Ipratropium use has also been associated with higher risk of
arrhythmias and stroke in large retrospective observational
studies.(Wilchesky, 2012,Wang et.al., 2012)

Bronchodilatory effect may be intensified by -adrenergics&

CRITER
IA

EVIDENCE

After inhalation a significant amount of tiotropium

reaches the systemic circulation, and, as a
consequence, muscarinic M3 receptors at other sites
in the body can be blocked for an extended time.
The systemic activity of tiotropium is the cause of
bothersome side effects such as dry mouth and
constipation, which have been seen more frequently
with tiotropium especially in elderly patients.These are
reversible and rare for inhalational therapy.
(Wedzicha, 2013)

2/3

POIN
T

Inhalational LAMAs are relatively safe and does not

pose any organ toxicity or serious ADRs such as
arrythmia etc. ((Decramer et.al., 2014)

++

CRITER
IA
1/2/3/4

EVIDENCE
POIN
T

Free combinations of LAMA/LABA also seem

well tolerated.
No differences in blood pressure and pulse rate +++
+
were observed with tiotropium plus salmeterol
versus single-agent therapies
meta-analysis
of
tiotropium
plus
The
formoterol data reported no differences in
cumulative incidence of adverse events for the
combination (33.2%) versus tiotropium alone
(36.0%), stating that drug-related severe
adverse events and cardiac effects were
relatively rare. (van Noord et.al., 2010)

CRITER
IA

EVIDENCE

1/2/4

long-term SAMA monotherapy on regular basis is not

recommended due to its short-lasting form which
works in about 15 minutes and lasts for 68 hours,
and is usually taken 4 times a day which diminishes
patients compliance to the drug (Voshar, et.al.,
2008; COPD, 2015).

No contraindication on the patient. SAMA is

contraindicated in patients with hypersensitivity to
atropine-like substances. Special precautions in
taking the drug must be given to patients with
narrow-angle glaucoma & prostatic hypertrophy,
cystic fibrosis.

POIN
T

CRITE
RIA

EVIDENCE

For both beta2-agonists and anticholinergics, long-acting

formulations are preferred over short-acting formulations.
(COPD, 2015)

Tiotropium bromide, as a monotherapy, is a once-daily,

long-acting mAChR antagonist (LAMA) with high potency
and kinetic selectivity at the mAChRs. (Barnes, 2000;
Littner et al., 2000)

No contraindication for the patient. Contraindicated for

those with hypersensitivity to atropine or ipatropium and
precaution for those with narrow angled glaucoma.

Tiotropium also results in better patient compliance due to

its once daily dosing as compared to SAMA (Vincken et.al.,

POIN
T

CRITE
RIA

EVIDENCE

1/2

Most specialists believe that patients not controlled by a

single
bronchodilator
should
be
given
two
bronchodilators with different mechanisms of action
(Mahler et.al.,2013)
GOLD recommendations indicate that the combined use
of short- acting b-agonists or LABAs and LAMAs may be
considered if symptoms are not improved with single
agents (GOLD, 2015)
According to the NICE guidelines treatment with LAMAs
plus LABAs is recommended in people with COPD who
remain symptomatic on treatment with a LABA alone
(NICE, 2010)

POIN
T

No

contraindication

for

the

patient.

LABA/

LAMA

++

PART 2

CRITERI
A

EVIDENCE

1/2

Clinical trials have also shown chronic use of LAMAs not

only reduces airflow limitation due to the disease but are
also associated with improvements in quality of life,
symptom scores and reduced exacerbations (Decramer
et.al., 2014; Wedzicha et.al., 2013; Vincken et.al., 2002).
Studies observed the ability of LAMAs to suppress mucus
secretion thereby reducing the colonization with bacteria
that trigger exacerbation events (Decramer et.al., 2014)

++

Long-term studies have shown no evidence of diminished

responsiveness (tachyphylaxis) with regular therapy.
(Seale, 2006).

Tiotropium,
once
administered
the
onset
of
bronchodilation occurs within 30 minutes, with peak
activity at 3 hours and sustained over more than 24

POIN
T

CRITER
IA

EVIDENCE

After inhalation a significant amount of tiotropium

reaches the systemic circulation, and, as a
consequence, muscarinic M3 receptors at other sites
in the body can be blocked for an extended time.
The systemic activity of tiotropium is the cause of
bothersome side effects such as dry mouth and
constipation, which have been seen more frequently
with tiotropium especially in elderly patients.These are
reversible and rare for inhalational therapy.
(Wedzicha, 2013)

POIN
T

CRITER
IA

EVIDENCE

2/3

A meta-analysis study conducted by Singh et.al.

(2008)
show
elevated,
but
non-statistically
significant point estimates for the outcomes of
death, MI or major adverse cardiac events.
Stephenson and colleagues (2011) found that new
users of inhaled anticholinergics were significantly
more likely to have had healthcare interventions for
acute urinary retention, with ipratropium and
tiotropium showing similar risks.

POIN
T

++